Senior Reimbursement Analyst

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions.

POSITION PURPOSE

Independently researches, analyzes, develops and maintains new and existing, complex reimbursement programs. Designs system specifications that support claims payment and criteria for data bases that support analysis as well as training documentation describing programming, billing and payment guidelines for internal and external use. Designated staff may focus primarily on supporting the Medicare Advantage line of business.

NATURE AND SCOPE

• This role does not manage people
• This role reports to this job: MANAGER, PROVIDER REIMBURSEMENT
• Necessary Contacts: In order to effectively fulfill this position the incumbent must be in contact with:All levels of internal personnel, with primary contacts in Network Administration, IT, Medical Management, Benefits Administration, Actuarial, Legal, Executive, Marketing, and Underwriting. Providers, provider representatives, consultants, provider specialty organizations, AMA, vendor reps, and hospital administrators to exchange or review program information. Other data sources are market research consultants, AMA, St. Anthony, Relative Value Studies for Dentists, Dun and Bradstreet and HIAA, CMS, Blue Cross and Blue Shield Association, Blue Cross and Blue Shield Plans, CMS, DHS, sales and marketing regional offices.

QUALIFICATIONS

Education

• Bachelor's degree in statistics, accounting, finance, math or related field is required
• Prefer a Master's Degree or pursuit of a Master's degree in Business, Information System and Decision Sciences, Healthcare Administration or Public Health.
• Four years of related experience can be used in lieu of a Bachelor's degree.

Work Experience

• 4 years of experience in the health industry accounting functions including billing, coding, Medicare or statistical analysis of financial information is required
• Provider contract analysis and/or reimbursement program implementation experience is strongly is preferred

Skills and Abilities

• Must have acquired sufficient knowledge to function autonomously and to know the appropriate contacts within departments to resolve specific issues for all lines of business.
• Excellent analytical, oral and written communication, and report preparation skills with highest degree of accuracy are required. Must have the ability to effectively present information to Executive Management and all levels of employees.
• Requires strong math/analytical skills including variance analysis, statistical formulas, algebraic formulas, percentages, multiplication and division, fractions and reasonableness tests.
• Excellent attention to detail, research, and documentation skills are required.
• Proficiency with commonly used database, spreadsheet and word processing software is required. Must have extensive knowledge to select the appropriate database format and structure for the type of information to be captured and reported. Familiarity with relational database software, mainframe capabilities, FOCUS and SQL programming is helpful and preferred. Must be able to create and maintain required databases as determined by supervisor.
• A strong understanding of physician charge practices and billing methodologies is helpful.
• Minimal travel is required. Travel may involve going to regional offices and/or conferences and exhibits.
• Staff dedicated to supporting Medicare Advantage must have working knowledge of Medicare enrollment guidelines and reimbursement.

Licenses and Certifications

• Pursuit of coding (CPC or CPHC) designation is preferred

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• Serves as provider reimbursement technical advisor and/or committee participant to Information Technology staff, Benefits Administration staff, Provider Audit, Network Administration and/or Medicare Advantage staff, and entry level Reimbursement Analyst by developing and implementing project/program narratives and responding to concerns on new and existing reimbursement programs, billing guidelines, and system requirements to ensure accurate implementation and maintenance of provider reimbursement programs.
• Identifies claims and provider reimbursement related system problems, including claims coding and processing issues, coordinates research, audit, and recommendations with Provider Audit, and implements and monitors system changes to resolve any problems.
• Researches, designs, implements, and maintains complex hospital or professional provider reimbursement programs for traditional and managed care programs and Medicare Advantage. Contact other plans, consultants, and local providers to assist in program specifications. Proactively monitors health care and health industry developments, including CMS/Medicare eligibility, EGWP and methodology changes. Analyzes and produces management reports to monitor effectives and identify and resolve deficiencies of reimbursement programs in comparison to industry benchmarks, competitors, and Medicare.
• Leads in the development of complex financial pricing models and financial data analysis to support modifications to reimbursement programs and monitor effectiveness of pricing logic.
• Provides statistical reports to Network Administration, Medical Management, Marketing and Medicare Advantage to support internal strategies and external customer needs, such as contract negotiations and marketing efforts.
• Complies with Corporate Objectives on project implementation and schedule deadlines. Ensures proper workflow by assessing reimbursement processes and recommending improvement as well as coordinating projects and time frames with less senior reimbursement staff.
• Accountable for complying with all laws and regulations associated with duties and responsibilities.

Additional Accountabilities and Essential Functions

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

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An Equal Opportunity Employer

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Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.

JOB CATEGORY: Data Analytics/Warehousing, & Business Intelligence